APPLICATION FORM FOR SKY HEALTH

Applica on No. Date

Personal Details
Provider Name Establishment
Name
Name(s) of the Provider(s) Mobile No.
to a end training (1stapplicant)
Rela on between Mobile No.
two a endees (2ndapplicant)
Address of the Sky Health franchise
Village Block

District Post Box Pin

number code
Nearest public health facility Nearest
(PHC / Dispensary name) Lab/chemist
Miscellaneous Informa on
Year of Prac ce Past Work Experience

Average number of Alternate Mobile number

Pa ents in a Month
GPS Coordinates Longitude La tude

Provider's Educa onal and professional qualifica on

Name as in records School Graduate/Post Graduate Computer Knowledge Professional Qualifica on
Provider 1
Provider 2
Occupa on of Sky Health franchise
Compounder Nurse RMP Pharmacist Others (please specify)
1.
2.

Training Fees (if any) Rs.

Preferred Mode of Payment

Cash Dra

Payment Details
Amount Bank Dra No./Transac on number Date of deposit Issuing bank In favor of

Bank Details for receiving payment from WHP (if any)

Name of Account Holder Bank Account No. IFSC code Bank Name

Self-a ested Photograph of the applicant Name and Signature of Field Person Name and Signature of Provider
 TERMS AND CONDITIONS
The applicant has expressed the desire to join the network of Sky Health Providers. World Health Partners (WHP) reserves the right to accept or
reject the applica on without assigning any reason.
1. If applica on is accepted, WHP will provide training to the applicants enabling them to join or re-join the Sky Health network.
2. WHP will ini ally provide the training on tuberculosis, family planning and tele-consulta on of medical care but may add other subjects in
the future which are determined by WHP to be crucial for improving the health of the community.
3. WHP will arrange to provide training, cer ficate, training materials, referral coupons, diagnosis coupons, TB no fica on register and
courier pouches.
4. The applicant has agreed to arrange for his/her own computer, printer and a glucometer before a ending the training to ensure work
starts immediately upon their return to their place of work.
5. A er successful training a cer ficate will be awarded. Once the cer ficate is issued, the contents in this applica on along with terms and
condi ons will form the basis of the financial and opera onal rela onship between the applicant and WHP.
6. The applicant a er training (“Sky Health or SH Provider”) will be responsible for
a. Referring the presump ve TB cases for sputum microscopic examina on to labs networked by WHP
b. Upda ng report through call centre for registra on
c. HIV & diabetes tes ng of confirmed TB pa ents (Refer to Annexure 1 for payment details)
d. Helping the pa ent get free Genexpert test from Government laboratories and Government-supplied free medicines from WHP's
networked pharmacies
e. Ensuring adherence of TB pa ents to treatment and its successful outcome
f. Maintain data on TB no fica on register
g. Iden fying poten al clients for family planning services that WHP will provide (Refer to Annexure 1)
h. Facilita ng tele-consulta ons with WHP's empaneled doctor for which WHP will charge a fee (see Annexure 2).
7. For all other services, the providers can refer pa ents to other health facili es selected at the provider's discre on.
8. Sky Health providers will get incen ve for TB no fica on and adherence un l comple on of treatment as per Annexure 1
9. By signing the applica on and receiving cer ficate a er training, the SH provider undertakes to conduct ac vi es that are in conformity
with the legal, medical, ethical and social norms and laws of India, WHP is not responsible for any illegal ac vi es or the outcomes thereof.
The provider shall not directly or indirectly indulge in any ac vity related with promo on or execu on of sex determina on or abor on.
Further, the provider agrees to provide access to the first party of all documents and reports for verifica on of the compliance of the same.
10. WHP reserves the right to terminate this agreement in the event of provider viola ng the guidelines and norms as men oned in this
applica on.
11. WHP may unilaterally modify the guidelines and norms at any me which will be binding on providers joining the network.
12. WHP reserves the right to select any number of SH providers from the same village / geography.
13. The contract between WHP and the SH provider can be terminated by either side by giving a 30-day no ce.
14. In case of termina on of contract,
a. The SH provider will return all items belonging to WHP (including cer ficate) and will no longer be allowed to use the Sky Health name
and logo.
b. Both par es reserve the right to inform the community about the closing of the Sky Health centre.
15. The SH provider also will not duplicate any of the protocols and printed materials provided by WHP without obtaining prior wri en
permission from WHP.
16. WHP can use the name / photo/video of providers, photo/video of SH centres, tele-consulta on images to highlight important aspects of
the project to the general public.
17. This agreement's scope is limited to undertaking services for which training was imparted by WHP or its assignees as men oned in point 3.
WHP will not be responsible for any other services performed by the SH provider.
18. The SH provider will not be involved in any illegal ac vity and will abide by all the norms and guidelines set by the government (as
amended from me to me). In case of involvement in any illegal ac vity, WHP may terminate the contract with immediate effect.
This agreement will be valid un l March 31, 2023, which can be further renewed on such terms and condi ons as may be mutually agreed
between both the par es
Declara on: I agree with the above men oned terms and condi ons. The contents of the applica on are TRUE and WHP reserves the right to
revoke the enrolment of the applicant or SH provider if any contents are found to be false or misleading.

Signature: Date:

Annexure I Annexure II
Directly from WHP or Facilitated through Government Charges for Tele-consulta ons
Type / Details Rate (TB valida on is a general consulta on)
TB no fica on Rs 500 / Pa ent1 Type / Classifica on4 Rate / Consulta on5
1
Comple on of TB Treatment Rs 500 / Pa ent
HIV and blood sugar test General Consulta on Rs 110 / Consulta on
of TB pa ent Rs 120 / Pa ent2
As per SH Provider Cri cal Care Consulta on Rs 200 / Consulta on
Steriliza on
terms with ASHA3
1 These payments will be made directly by the Government through DBT (Direct Benefit Transfer) on 4 The decision of WHP will be final and binding on classifica on of the consulta on
the recommenda on of WHP. Please ensure accuracy of bank account of the Sky Health provider to 5 Rates are subject to unilateral change by WHP
receive the payments.
2 WHP will make the payment directly to the SH provider's bank account on submission of the report
per WHP template within 10 days of conduct of tests.
3 Steriliza on incen ve- Under current government rules, only an ASHA is en tled to a steriliza on
incen ve Rs 300 per client. Sky Health providers are encouraged to e up with local ASHAs for sharing
the incen ves.
 
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thih,l funsZ'kkad ns'kkarj v{kka'k
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uke Ldqy Lukrd@LukrdksÙkj daI;wVj esa Kku is’ksoj ;ksX;rk
izksokbMj 1
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I II
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